Transcript Heart Failure

Heart Failure
Internal Medicine Workshop Series
Laos
September /October 2009
Definition
• Heart cannot pump enough blood to meet
body’s needs
• Heart is too weak or too stiff to fill and pump
properly
How does it affect our patients?
• Decreases quality of life
• Decreases activity level
• Decreases survival
– Annual mortality of 5% -50%
Types of heart failure
• Chronic
– A long term condition with signs and symptoms
that persist
• Acute
– An emergency situation that occurs when
something affects your heart’s ability to function
• acute myocardial infarction
• acute arrhythmia
Types of heart failure
• Left sided
– Fluid backs up into lungs
• Right sided
– Often occurs with left sided heart failure
– Fluid backs up into abdomen, legs and feet
• Systolic
– Ventricle cannot contract properly, poor pumping
• Diastolic
– Ventricle cannot relax properly, poor filling
Systolic
Diastolic heart failure
Causes of heart failure
• Develops after other diseases damage or
weaken the heart
• The ventricles become weak, dilated and do
not pump blood efficiently through the body
(systolic failure)
• The ventricles become stiff and do not fill well
between heartbeats (diastolic failure)
Causes of heart failure
• Coronary artery disease and myocardial
infarction
– Ischemia to heart muscle
• Hypertension
– Heart muscle must work harder
• Valvular heart disease
– Damaged valves causes heart to work harder
Causes of heart failure
• Cardiomyopathy
– Damage to heart muscle from infection, alcohol,
drugs, thyrotoxicosis, lupus, or idiopathic (no
cause found)
• Myocarditis
– Inflammation to heart muscle from viral infection
or autoimmune disease
• Congenital heart defects
– Healthy parts work harder
Causes of heart failure
• Arrhythmia
– Heart muscle must work harder
• Other diseases
– e.g. diabetes, thyroid disease, severe anemia,
emphysema cause chronic heart failure
– e.g. severe sepsis, pulmonary embolism, allergic
reactions cause acute heart failure
Clinical presentation left sided
• All related to pulmonary congestion
– Dyspnea
– Orthopnea
– Paroxysmal nocturnal dyspnea
– Cough
– Fatigue
– Weakness
Clinical presentation right sided
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Peripheral edema
Abdominal distention
Weight gain
Nocturia
Cardiac findings
Systolic dysfunction
• Tachycardia
• Hypotension
• S3
• Apical impulse is more
lateral, and lasts longer
• Left ventricular lift
• Elevated jugular venous
pulse
Diastolic dysfunction
• Tachycardia
• Hypertension
• S4
• Apical impulse is in proper
position, but lasts longer
• Left ventricular lift
• Elevated jugular venous
pulse
New York Heart Association
functional classification
Class
I
II
III
IV
Definition
No symptoms
Symptoms with ordinary activity
Symptoms with less than ordinary
activity
Symptoms at rest or with any minimal
activity
Drugs
DRUG
Mechanism of action
For patient
Angiotensin
Dilates blood vessels
converting enzyme Decreases blood pressure
(ACE) inhibitors
Improves blood flow
Decreases work of heart
Live longer
Feel better
Angiotension II
receptor blockers
(ARBs)
Same as ACE inhibitor
Live longer
Feel better
Beta Blockers
Slows heart rate
Decreases blood pressure
Live longer
Feel better
Drugs
DRUG
Mechanism of action
For patient
Digoxin
Increase heart muscle contraction Feel better
Slows heartbeat
Diuretics
Increases urination
Prevents fluid accumulation
Feel better
Hydralazine Dilates blood vessels
and nitrates
Feel better
Aldosterone Reverses scarring of heart
antagonist Prevents fluid accumulation
Feel better
Live longer
Treatment all patients
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Educate patient
Cardiovascular risk reduction
Lifestyle modification (exercise, decrease stress)
Limit salt (1-3 gms daily)
Limit fluid (1.5-2 litres daily)
Limit alcohol
Treat cause (ie hypertension, ischemia)
Diuretic therapy
Treatment if NYHA II
• Add angiotensin converting enzyme (ACE)
inhibitor
• Add beta blocker
Treatment if NYHA III-IV
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Add ARB (angiotension receptor blocker)
Add digoxin
Add hydralazine and nitrates
Add spironolactone
3 cases
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Is the heart failure chronic or acute?
Is it mostly right sided or left sided?
Is it systolic or diastolic?
What is the cause?
What is the NYHA classification?
How should we treat now?
Case number 1
• 55 year old male with known coronary artery
disease, previous myocardial infarction and
previous admission for heart failure
• Discharged from hospital two weeks ago on
angiotension converting enzyme inhibitor and
furosemide
• Returns with mild dyspnea when walking, and
orthopnea
• Exam shows S3, tachycardia, elevated JVP
Case number 2
• 45 year old woman with no known heart
disease
• Had hypertension during both pregnancies
• Has symptoms of dyspnea for 3 months when
doing housework
• Has BP 170/70, heart rate of 100, elevated
JVP, S4, few crackles in lungs, and mild
peripheral edema
Case number 3
• 40 year old male with no heart disease
previous
• Drinks a lot of alcohol and has poor nutrition
• Presents to hospital severely short of breath
and cyanotic
• Has crackles in lungs, elevated JVP, S3,
abdominal distention and peripheral edema
• Treated in ED with furosemide and nitrates,
now better